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10: 1b 2099337061 SUSD HEALTH SERVICES t'AUL 02/03 <br /> i P.� SAN JOAQUIN COUNTY a Rhe 1��'\P <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N f 600 East Main Street, Stockton,CA 95202-3029 �r 9 20 <br /> :•.,�� ;��P/ Telephone. (209)468-3420.Fax. (209)468-3433 Web.www.sjgov.org/ehd SAN O �n <br /> .��i F ti .✓ EN R1V 1 U CCUN <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI&QHt)E AR EMT <br /> To qualify for a"Limited.Quantity Hauling Exemption."pursuant to the"Medical Waste Management Act",the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,transport less <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the <br /> generator or parent organ,iiation has on file one of the following: <br /> 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator <br /> or a small quantity generator required to register pursuant to Chapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not.required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: <br /> Son Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> Cl New Kj Renewal <br /> Medical Office/13usln.essName• Stockton Unified School District <br /> Medi.caI Office/Business Address: 701 N. Madison, Street <br /> Stockton CA 95202 <br /> City State Zip Cade <br /> Contact Person: Tammy Evans, Administrator _ <br /> Phone Number: 209.933.7060 <br /> Storage Facility Name: Stockon Unified Health Services Dept. <br /> Storage Facility Address: 1.144 E. Channel Street <br /> Stockton CA 95205 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle, Inc. <br /> Permitted Treatment Facility Address: 4135 W. Swift <br /> Fresno, CLQ 93722 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(.If more than 3,attach info): <br /> 1.Name: See attachment Title: <br /> 2.Name: Title: <br /> 3.Name: Title: <br /> A copy of this exemption and a tracking document shall fie in employee's possession at.all times while transporting medical waste. in <br /> addition,all copies of medical waste records shall he kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Ftrr., Date. 10/18/10 <br /> Title: Administrator of H alth Servicas Dept. - <br /> DO NOT WRITE BELOW THIS LINEab�3 <br /> R.E.H.S. Application Approval. Date: <br /> Expiration Date:-b-Z/ 31/-a Date Paid;kO /Zq / lb EaWt oi-Check#! `jg al OSS Received By_ <br /> MD 45-01 <br />